- Not to be confused with Ganglion (nervous tissue structure).
| Ganglion cyst |
| Classification and external resources |
Cyst on dorsum of left hand |
| ICD-10 |
M67.4 |
| ICD-9 |
727.4 |
| DiseasesDB |
31229 |
| eMedicine |
orthoped/493 |
| MeSH |
D045888 |
A ganglion cyst, also known as a Bible cyst or Bible bump, is a benign soft tissue tumor that may occur in any joint, but most often occurs on or around joints and tendons in the hands or feet.[1]
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Contents
- 1 Etymology
- 2 Cause
- 3 Histopathology
- 4 Clinical features
- 5 Diagnosis
- 6 Treatment
- 7 Complications
- 8 Prognosis
- 9 Additional images
- 10 See also
- 11 References
- 12 External links
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Etymology [edit]
An apparent misnomer,[2] the ganglion cyst is unrelated to the neural "ganglion" or "ganglion cell"; its etymology traces back to the ancient Greek γάγγλιον, a "knot" or "swelling beneath the skin",[3] which extends to the neural masses by analogy. Hippocrates is generally credited with their description.[4][5]
The term "Bible cyst" (or "Bible bump") is derived from a common treatment in the past that consisted of hitting the cyst with a Bible or similarly large book.[6] Striking the ganglion cyst with a large tome is usually sufficient to rupture the cyst, and re-accumulation is uncommon.[7]
Cause [edit]
The most commonly accepted cause of ganglion cysts is the "herniation hypothesis", in which they occur as "an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath." This is based on the observations that the cysts occur close to tendons and joints, the microscopic anatomy of the cyst resembles that of the tenosynovial tissue, the fluid is similar in composition to synovial fluid, and dye injected into the joint capsule frequently ends up in the cyst, which can become enlarged after activity. However, dye injected into the cyst rarely enters the joint, which has been attributed to the formation of an effective "check valve" allowing fluid out of the joint, but not back in.[4] Synovial cysts, posttraumatic degeneration of connective tissue and inflammation have been considered as the causes. Other possible mechanisms for the development of ganglion cysts include repeated mechanical stress, facet arthrosis, myxoid degeneration of periarticular fibrous tissues and liquefaction with chronic damage, increased production of hyaluronic acid by fibroblasts, and a proliferation of mesenchymal cells. Ganglion cyst can develop independently from a joint.[8][9]
Histopathology [edit]
Ganglion cyst of the hand with multiple cystic chambers containing glairy material. The walls are composed of bland fibrous tissue with no specialized lining.
They are thin-walled cysts containing clear, mucinous fluid.[10]
Clinical features [edit]
The average size of these cysts is 2.0 cm, but cysts of more than 5 cm have been excised.[4] The size of the cyst may vary over time, and can increase after activity.
Sites [edit]
It is most frequently located around the dorsum of the wrist and on the fingers. A common site of occurrence is along the extensor carpi radialis brevis as it passes over the dorsum of the wrist joint. Although most commonly found in the wrist, ganglion cysts may also occur in the foot.[10]
Ganglion cysts are "commonly observed in association with the joints and tendons of the appendicular skeleton, with 88% "in communication with the multiple small joints of the hand and wrist" and 11% with those of the foot and ankle.[4] They are most often found around the wrist joint, especially at the scapho-lunate area, which accounts for 80% of all ganglion cysts.[citation needed]
In a 2007 study of patients whose foot lumps were being surgically removed in Glasgow, 39 of 101 cases were ganglion cysts. The study replicated an earlier result that no ganglion cysts were found on the sole or heel of the foot; the authors wrote that "Although lumps in these areas may be ganglia, the surgeon should probably consider other diagnoses in the first instance." They also noted a marked female preponderance (85%) and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery.[11]
Ganglion cysts can also occur about the knee, commonly near the cruciate ligaments, also at the origins of the gastrocnemius tendon and anteriorly in Hoffa's infrapatellar fat pad.[12]
From their common origin at the joint or tendon, ganglion cysts can stray into a wide range of locations. Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue.[4][13] Very rare cases of intramuscular ganglion cysts in the gastrocnemius muscle have been reported.[14][15] It is possible for the cyst to be displaced considerably from its connection to the joint. In one extreme case a ganglion cyst was observed to propagate extensively via the conduit of the common peroneal nerve sheath to a location in the thigh; in such cases surgery to the proximal joint to remove the articular connection can remove the need for a riskier, more extensive surgery in the neural tissue of the thigh.[16] The cysts can even intrude into the spine, which can cause pain and dysesthesia in distant extremities.[8]
It has recently been proposed that cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, may occur by an articular mechanism, with a conduit leading from the joint, similar to the development of ganglion cysts that spread within the peroneal nerve.[17]
Cysts have also been reported to occur nearby to shoulder joint, compressing one or more nerves and causing bone erosions.[18]
Diagnosis [edit]
Ganglion cysts are easily diagnosed, as they are visible and pliable to touch.
Radiographs in AP and lateral views are obtained to exclude any more serious underlying pathology.[19] Ultrasound may be done to detect the presence of occult cysts.[20]
Treatment [edit]
Surgical treatments remain the primary option, other than doing nothing at all, for the treatment of ganglion cysts. Arthroscopic surgery of the wrist is becoming available as an alternative to open excision of ganglion cysts. Alternatively, a hypodermic needle may be used to drain the fluid from the cyst (aspiration) and a corticosteroid is injected after cyst is empty.[20] However, if the fluid has become thick owing to the passage of time, this treatment is not always effective.[citation needed]
An outdated method of treating a ganglion cyst was to strike the lump with a large heavy book, causing the cyst to rupture and drain into the surrounding tissues. Since almost every home owned a Bible and it was often the largest book in the home, this is what was commonly used, which led to the nickname of "Bible bumps" or "Gideon's disease."[6]
Complications [edit]
Complications of treatment include stiffness in hand and scar formation.[20]
Prognosis [edit]
Recurrence rate is higher in aspirated cysts than in excised ones.[19] Excised ganglion cyst may recur in 5-15% cases, usually because the cyst was not completely removed.[20]
Ganglion cysts have been found to recur following surgery in 12%[21] to 41%[22] of patients.
A six-year outcome study of treatment of ganglia on the back (dorsum) of the wrist compared excision, aspiration and no treatment. Neither excision nor aspiration provided long-term benefit over no treatment. Of the untreated ganglia, 58% resolved spontaneously; the post-surgery recurrence rate in this study was 39%.[23]
A similar study in 2003 of palmar wrist ganglion states: "At 2 and 5 year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated or left alone."[24]
Additional images [edit]
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Cyst on wrist of right hand
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Cyst located on right wrist
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Cyst on dorsum of right foot
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Cyst on dorsum of left hand
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Cyst on dorsum of left hand
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See also [edit]
- Ganglioneuroma
- List of cutaneous conditions
References [edit]
- ^ McDonald, RE; Mullens, DJ (May 2013). "Ganglion cyst treatment using the ganglion suture technique". Osteopathic Family Physician 5 (3): 123–127. doi:10.1016/j.osfp.2013.01.006.
- ^ J.C. Segen (1992). The Dictionary of Modern Medicine. (see the entry for aneurysmal bone cyst, which "like pyogenic granuloma and ganglion cyst, a misnomer that has withstood the sands of time and the dint of logic")
- ^ "Etymology of the Greek word ganglion (γάγγλιον)".
- ^ a b c d e Craig A. Camasta, DPM (1993). "excision of the ganglion cyst". Podiatry Institute.
- ^ See Hippocrates' "On the Articulations" (part 40) at Wikisource
- ^ a b http://www.eatonhand.com/hw/hw013.htm
- ^ Kumar, Vinay (2007). Robbins Basic Pathology. Philadelphia, PA: Saunders Elsevier. p. 825. ISBN 978-1-4160-2973-1.
- ^ a b Sang Woo Kim et al. (2011-04). "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen". J Korean Neurosurg Soc. 49 (4). pp. 237–240. doi:10.3340/jkns.2011.49.4.237. (original source cites eight additional references for the quoted paragraph)
- ^ Ribes, Ramón (2010). Learning Musculoskeletal Imaging. Springer. p. 197. ISBN 9783540880004.
- ^ a b McNabb, J. W. (2005). Practical Guide to Joint and Soft Tissue Injection and Aspiration. Lippincott Williams & Wilkins. pp. 62–65. ISBN 9780781753630.
- ^ Duncan JM Macdonald et al. (2007-08). "The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years". Ann R Coll Surg Engl. 89 (3): 272–275.
- ^ Jon Arthur Jacobson (2007). Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences.
- ^ "Intraosseous ganglion cyst of the humeral head in a competitive flat water paddler: case report". J Can Chiropr Assoc. 55 (4): 294–301. 2011-12. (includes MRI images)
- ^ Jae Jeong Park et al. (2010). "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle". Korean Journal of Dermatology.
- ^ Soonchan Park MD et al. (2009-10). "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: Sonographic appearance". Journal of Clinical Ultrasound 37 (8). pp. 478–481.
- ^ Robert J. Spinner et al. (2012). "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" 22 (4). Turkish Neurosurgery. pp. 527–528.
- ^ R. J. Spinner et al. (2012-08-29). "Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected.". Clin Anat. doi:10.1002/ca.22152.
- ^ Field, Larry D. (2003). MasterCases: Shoulder and Elbow Surgery. Thieme. p. 241. ISBN 9780865778733.
- ^ a b Pocket Guide to Musculoskeletal Diagnosis. Springer. 2005. p. 63. ISBN 9781597450096.
- ^ a b c d The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1. Gale. 2003. p. 560. ISBN 9780787677213.
- ^ Gallego S, Mathoulin C. (2010). "Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years". Arthroscopy 26 (12): 1675–1682. PMID 20952152.
- ^ Lidder S, Ranawat V, Ahrens P. (2009). "Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction". Orthop Rev 1 (1): e5. PMID 21808669.
- ^ Dias JJ, Dhukaram V, Kumar P, The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007 Oct;32(5):502-8.
- ^ Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg Br. 2003 Apr;28(2):172-6.
External links [edit]
- American Academy of Orthopaedic Surgeons - Ganglions cyst of the wrist
- Canadian Centre for Occupational Health and Safety - Ganglion cyst
- eMedicine - Ganglion cyst
- Medscape - Ganglion cyst
- Ganglion Cyst- Prime Health Channel
- "Ganglion Cyst Draining At Home" - Emphatically not an example of safe nor sterile surgical procedure, this video illustrates the appearance of the fluid in the cyst.
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Soft tissue disorders / Rheumatism / Connective tissue arthropathy (M65–M79, 725–728)
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| Capsular joint |
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Synoviopathy
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Synovitis/Tenosynovitis (Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome) · Transient synovitis · Ganglion cyst
osteochondromatosis (Synovial osteochondromatosis) · Plica syndrome
villonodular synovitis (Giant cell tumor of the tendon sheath)
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Bursopathy
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Bursitis (Olecranon, Prepatellar, Trochanteric, Subacromial, Achilles, Retrocalcaneal, Ischial, Iliopsoas) · Synovial cyst (Baker's cyst) · Calcific bursitis
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| Noncapsular joint |
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Ligamentopathy
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Ligamentous laxity · Hypermobility
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Enthesopathy/Enthesitis
(and general tendinopathy)
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upper limb (Adhesive capsulitis of shoulder, Impingement syndrome Rotator cuff tear, Golfer's elbow, Tennis elbow)
lower limb (Iliotibial band syndrome, Patellar tendinitis, Achilles tendinitis, Calcaneal spur, Metatarsalgia) · Bone spur
other/general: Tendinitis · Tendinosis
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| Nonjoint |
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Fasciopathy
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Fasciitis: Plantar · Nodular · Necrotizing · Eosinophilic
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Fibromatosis/contracture
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Dupuytren's contracture · Plantar fibromatosis · Aggressive fibromatosis · Knuckle pads
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noco (arth/defr/back/soft)/cong, sysi/epon, injr
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anat (h/n, u, t/d, a/p, l)/phys/devp/hist
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noco (m, s, c)/cong (d)/tumr, sysi/epon, injr
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